Cesarean section, a life-saving operation for both
fetus and mother, accounts for approximately 20% of deliveries in the
United States today. The lower cervical transverse incision for this
operation has become the accepted technique, except in cases in which
compound presentations require the classic vertical incision in the
fundus of the uterus.

The purpose of the operation is to deliver the
fetus through the abdomen in instances where vaginal delivery would
be either impossible or dangerous to the life or health of the mother
and/or fetus.

Physiologic Changes. There are many differences in
the physiologic changes between vaginal delivery and cesarean section.
Fetuses delivered by ceaseran section may have a higher incidence of
respiratory distress syndrome. On the other hand, vaginal delivery
with dystocia can produce central nervous system damage. Further discussion
involving the physiology of cesarean section is beyond the scope of
this text, and the reader is referred to the obstetrical literature
for additional information.

Points of Caution. The
anesthesia for cesarean section should be selected with care. An
epidural regional block is recommended, since this has the least
chance of causing fetal depression.

If general anesthesia is to be
used, the anesthesiologist should be consulted to ensure proper timing
between the infusion of the rapid-acting barbiturates and delivery
of the baby in order to minimize any depressing effect on the central
nervous system of the fetus. Care should be exercised in dissecting
the bladder off the lower uterine segment to prevent laceration of
the bladder during the procedure. If, by chance, excessive manual stretching
of the transverse incision should lacerate the uterine vessels in the
broad ligament, this ligament should be opened. The uterine vessels
should then be carefully dissected out and individually ligated to
prevent postoperative hematoma and possible damage to the underlying
ureter.

Technique

For cesarean section, a Foley catheter is
placed in the bladder, and the patient is placed in the dorsal
supine position. The abdomen is surgically prepped. The abdomen
can be opened through a lower transverse incision or a midline
incision.

After opening the abdominal cavity, the vesicouterine
fold is identified and opened. Moist packs can be placed in the
lateral gutters on each side of the uterus to prevent blood and
fluid from draining into the peritoneal cavity.

When the bladder has been dissected down,
a small transverse incision is made in the lower uterine segment
with a scalpel.

An opening is made in the
amniotic sac large enough to admit two fingers.

The fingers are inserted into the uterine
cavity.

The incision is stretched
laterally.

The appropriate fetal parts are grasped.

Occasionally, obstetrical forceps or the
hand is inserted to aid in removal of the fetus.

The fetus is removed.

The cord is doubly clamped and incised. The
fetus is immediately suctioned and handed to the pediatrician.

We prefer to deliver the uterus through the
incision. The placenta is manually extracted.

A retractor is inserted into the uterine
incision. The uterus is manually explored, and any remaining
placental membranes are removed under direct vision.

Excess blood in and around the incision is
removed by suction.

The first layer of 0 synthetic absorbable
suture is placed in the transverse incision as a continuous suture.
A second layer of interrupted 0 synthetic absorbable suture is
placed in the myometrium.

The serosa of the uterus and the vesicouterine
peritoneal fold are closed with continuois 3-0 synthetic absorbable
suture.